Flexibility and safety in times of coronavirus disease 2019 (COVID-19): Implications for nurses and allied professionals in cardiology

Never before have so many healthcare professionals been in the daily news worldwide as now, during the coronavirus disease 2019 (COVID-19) pandemic. Hospitals are intensifying their resources for patients in need of intensive care and respiratory support, converting wards into COVID-19 units and, at the same time, stopping or restricting non-life threatening diagnostic procedures and treatment, for instance elective surgery.

For the healthcare professionals working in cardiology, the COVID-19 pandemic has many consequences that might not be directly visible in day-to-day news coverage. Still, we struggle with similar issues in many countries around the world and this editorial addresses some aspects related to COVID-19 with the goal of enlarging our feelings of unity and solidarity in this field and learning from each other’s experiences.

Cardiology is a broad medical field including both acute and chronic aspects of care that are all affected by COVID-19. For healthcare providers, a lot of flexibility is asked for because of changes in schedules, job assignments, workplace, etc. But at the same time, cardiac patients ask for stability and security in care too; patients still need adequate diagnostics, treatment, education and follow-up.

Challenges to cardiac patients and families during the COVID-19 pandemic

Although a lot of patients can be managed well with support from a distance and are practising optimal self-care, many cardiac patients have problems and worries that are especially caused by the restrictions that the COVID-19 pandemic lays on society as well as the healthcare system.

Some of them are:

• - Worrying about delayed or cancelled diagnostics and treatment. For example, will my ICD be replaced in a timely manner or is it safe to delay my intervention or cardiac surgery. Others worry about their diagnostic angiogram that is postponed and wonder if it is safe or if they will have a heart attack.

• - Worrying about optimal care and readmission when out-patient follow-up visits are postponed or delayed, or when they are not admitted to hospital or discharged earlier than in a normal situation without COVID-19.

• - Feeling extra vulnerable and anxious as a cardiac patient and being advised of the need for total social distancing since they are at risk of becoming very ill or might die if affected by the coronavirus, or on the other hand feeling frustrated by being considered a ‘risk group’, while not feeling different than yesterday.

• - Being restricted in the ability to exercise in, for example, the rehabilitation centre at the hospital or the local gym.

• - Being afraid to get infected with COVID-19 and not knowing how to handle daily issues (for instance, what to disinfect and how often).

• - Becoming angry and frightened when others do not adhere to advice given by the government and healthcare authorities (for instance keeping a distance).

• - Feeling anxious and stressed when met by healthcare professionals in protective clothing or when met by healthcare professionals with no protection because of lack of protective equipment.

• - Worrying about deterioration while having acute severe symptoms of chest pain and shortness of breath and needing to be tested before receiving acute treatment or being hospitalised.

• - Delaying seeking healthcare with acute chest pain and not knowing if their complaints are severe enough to burden the healthcare system.

• - Worrying about if there will be enough resources to be treated with for example an acute PCI.

• - Getting worried or feeling panic from browsing the Internet for COVID-19 information without any guidance.

• - Having no realistic insight into the situation and feeling strong and immune, for instance feeling unrealistically safe on antibiotics and prednisolone.

• - Wondering about whether they should increase, stop or decrease their medications for example ACE-inhibitor or ARB or do other self-care activities if infected by COVID-19.

Challenges to cardiac healthcare professionals

Healthcare professionals need to stay updated constantly and adapt their advice to patients and also change their own professional and private behaviour. Some of our colleagues need to stay at home because of social distance restrictions on family members, COVID-19 symptoms, preventive quarantine or mental stress. Some colleagues are afraid to go to work in case of endangering themselves or their family.

A substantial number of professionals working in the departments of cardiology and cardiothoracic surgery are preparing to alter (have already altered) their daily clinical work, some have experienced having their ward rebuilt to be suitable for COVID-19 patients, some wards have closed completely to relocate staff to other acute care units. Staff are educated to take care of other patient groups than they usually treat (and have expertise in). ICUs are reorganised and rebuilt to the maximum of respiratory beds. Healthcare providers from medical, cardiology and cardiothoracic ICUs create large teams that can work across ICU COVID-19 units with similar equipment and protocols.

In a lot of cardiology out-patient clinics, obvious changes include moving to distance follow-up instead of a clinic visit and also extending the length of follow-up phone calls, since many patients want to talk about COVID-19 and what it means to them. In some hospitals, the pacemaker control period is extended from bi- or tri-monthly to yearly, most angiograms and electrophysiology procedures are cancelled. ICDs are monitored using tele-monitoring systems, preventing patients from coming to hospital after receiving a shock therapy and reassuring them by telephone. It is amazing how quickly telecare and distance monitoring have become almost ‘the new normal’ and how flexible patient and healthcare professionals are in adopting these practices. ¹

However, specific challenges of distance follow-up have also become painfully clear and need creative solutions. ² For example, it is more difficult to estimate whether a newly referred patient or his or her family can recognise signs and symptoms, such as leg oedema in heart failure patients, or whether they are able to decide if it is necessary to come to the hospital. In addition, in patients with visual or auditory impairments, it can be difficult to change medication by phone, especially when a patient does not have email or cannot read very well. For patients who are very lonely and feel socially isolated, and/or elderly patients, extra telephone contact with the clinic can be very important to ask questions and help to solve problems.

Uptitration of medication can be complicated without appropriate laboratory tests or physical examination of a patient. Every time one orders a laboratory test (at home or in an office) one has to balance the risk of exposing the patient to possible COVID-19 infection (or the healthcare professional in taking the blood) yet really needing the laboratory value to adapt medication, for example to make that last step in an uptitration schedule.

Valuable moments and creativity

Professionals and patients are constantly trying to find practical solutions, such as:

• - Use of video conferencing with patients or their family or, if this is too difficult, use of a picture on the phone to show, for instance, a wound or oedema.

• - Having ECG and laboratory tests done close to the patients (for instance at the GP because of fast AF).

• - More contact by email and regular mail.

• - Closer collaboration with primary care.

• - Sending information about websites where people can see how the heart works, what happens in cases of fluid retention etc.

• - Emphasis that patients and their family can contact the clinics and, when necessary, they can come to the hospital and will be treated.

Meanwhile, there appears to be a collaboration within and between disciplines and professions as never before. All healthcare workers must adapt to this new situation, and this is not only accompanied by fear and stress, but also by solidarity and heroic work. Similarly, in talking to patients and family members, valuable moments can also occur. For example, talking about life and death seems to be easier for some patients and family members in this exceptional situation. While patients feel much more vulnerable, healthcare workers in cardiology need to give flexible and secure patient care on an optimal level.